A SUPPORT AND INFORMATION NETWORK
The Diabetics Division of the National Federation of the Blind
Vol. 10, No. 2, Spring Edition 1995
The VOICE OF THE DIABETIC, published quarterly, is the national news magazine of the Diabetics Division of the National Federation of the Blind. It is read by those interested in all aspects of blindness and diabetes. We show diabetics that they have options regardless of the ramifications they may have had. We have a positive philosophy and know that positive attitudes are contagious.
News items, change of address notices, and other magazine correspondence should be sent to:
Ed Bryant, Editor
VOICE OF THE DIABETIC
1412 I-70 Drive SW, Suite C,
Columbia, M0 65203
Phone: (573) 875-8911
Fax: (573) 875-8902
Copyright ©1995 Diabetics Division, National Federation of the Blind.
VOICE OF THE DIABETIC is offered absolutely free to any interested person upon request. Readers may receive the publication in print, on audio cassette for the blind, or in both formats. To begin receiving the VOICE, please complete the subscription form (or a facsimile), located at the end, and mail it to the editorial office.
Update: Insulin Packaged in Uniquely
Shaped Vials Would Eradicate Errors
by Ed Bryant
Yes, There Is Life After Transplant
by Amy Walters
Increasing the Social Security Earnings Limit: A Critical Time of Decision for Blind People
Diabetes and Yeast Infections
by Diana W. Guthrie, PhD, FAAN, CDE
Diabetic Gastroparesis
by Joseph Tripodi, D.O. and Robert Burakoff, M.D.
Ask the Doctor
by Wesley W. Wilson, M.D.
One Alternative to Amputation
by Allan Nichols
Dialogs About Diabetic Dynamos
by Debra Frank, M.S., M.S.
Convention 1995: Make Plans
for Chicago
by Kenneth Jernigan
Type I Diabetes Prevention Trial
What You Always Wanted to Know but Didn't Know Where to Ask (Resource List)
How to Remember the Diabetics Division of the National Federation of the Blind in Your Will
Subscription/Donation Information and Form
Address for news items, change of address, etc.
by Ed Bryant
In April 1992, the Diabetics Division of the National Federation of the Blind began lobbying the Food and Drug Administration (FDA) and both United States insulin manufacturers to change insulin vial shapes. Currently all insulins are packaged in identical cylindrical vials, a practice which makes nonvisual identification of containers impossible. We are seeking to change this. Our goal is to enable insulin identification by tactile means, to improve both safety and the prospects for self-mangement.
The Diabetes Control and Complications Trial (DCCT) proved that metabolic control matters. "Tight control" means multiple insulin injection regimens are more common, but so is the opportunity for dosing errors. Insulin users who make dosing errors risk severe hypoglycemia and the possibility of death. Numerous articles have been published in Voice of the Diabetic, updating readers on the insulin vial dilemma. The FDA has consistently excluded blind consumers from the planning process. The bureaucrats and insulin industry, until recently, have given no consideration to changing insulin containers and/or label design to help the blind identify insulins. Both groups are fully cognizant that the Centers for Disease Control estimates each year 15,000 to 39,000 people become blind from diabetes. Unfortunately, they have assumed that blind diabetics would, of course, have sighted companions to draw up their insulins. They should know better. The notion that blind individuals are incapable of self management is false and unsupportable. Thousands of blind folks manage their diabetes independently and are involved in the mainstream. On June 21, 1994, Mr. John Short, a consumer safety officer from the FDA, told me that "someone who is totally blind would have someone else taking care of medication for them." My reply to this incredible statement was published in the Fall 1994 issue of the Voice. It said in part: "The time when disabled people were chained to the bed is long since over. Blindness is not synonymous with inability. Such discrimination against the disabled led to passage of the Americans with Disabilities Act in 1990." At the same time, we published the FDA's response from Solomon Sobel M.D., Director, Division of Metabolism and Endocrine Drug Studies, the Center for Drug Evaluation and Research. It said in part: "Subsequent to your conversations with Mr. Short, and in response to your letter dated June 22, 1994, we have decided to hold meetings with interested organizations including the National Federation of the Blind and the insulin manufacturers to determine what can be done to assist blind diabetics."
In the Voice, Winter 1995, readers learned of a December 1994 meeting I had with representatives of Eli Lilly and Company, in which we discussed concerns the blind have in identifying insulins. I was shown prototype vial holders of different shapes and colors. The company is now working on other possible solutions.
In January 1995, I met with representatives of Novo Nordisk Pharmaceuticals, Inc. On that occasion we discussed the same concerns, those the blind have in identifying insulins. Although we reviewed possible solutions, and the representatives said they would work on the ideas discussed, they have not yet developed prototype designs.
Possible solutions were discussed with representatives of both insulin manufacturers. Both groups indicated they would work with our Diabetics Division to alleviate this vexing problem. Placing tactile cues on the aluminum rings around the tops was discussed. I said I didn't believe bumps on the rings could provide enough information, but that in combination with tactile cues on container labels, would be a good start. I requested prototypes of whatever design(s) were developed. Eli Lilly and Novo Nordisk representatives were not enthusiastic about changing vial shapes. Both groups seemed more interested in changes that did not include altering actual bottle configurations. When more is known, readers will be updated.
The following are samples of letters to: Dr. David A. Kessler, Commissioner, Food and Drug Administration, 5600 Fishers Lane, Rockville, MD 20857. These Voice readers made their thoughts known!
January 2, 1995
Please be advised: Identification of insulin vials are long overdue. I have a blind daughter (developed diabetes at 13 months Ä now 47 years old) who is very independent, but not for long, unless vials are specially shaped or marked. Yes Ä yes Ä yes Ä I am in support of the needed changes in insulin vial shapes so they can be identified.
Beverly S. Ney
Mount Hermon, LA
January 2, 1995
Dear Dr. Kessler, As a blind diabetic may I suggest that you consider making mandatory a change in the insulin vial shapes and the addition of markings such that the variety of insulin types may be identified tactually. Presently the blind, many of whom are so due to diabetes, cannot with appropriate certainty know the kind of insulin in each vial. As a result, harmful dosing and dispensing errors happen. Therefore as a matter of public health and safety, your consideration of these simple but vital changes is much appreciated.
Thank you,
Gina Colonna
Somerville, MA
January 4, 1995
Dear Dr. Kessler, I am writing to express my personal support, and that of my staff, for the needed changes in insulin vial shapes. This change will not only help prevent dispensing errors for patients but also for health care providers. It is very easy for the consumer to grab the wrong vial. It is even easier for the blind consumer to choose the wrong vial. By changing the shape of insulin vials by insulin type, we will prevent unnecessary hospitalizations. I believe the consumer can best be served by changing the shape of the insulin vials.
Sincerely,
Linda Sterling, RN
Nurse Manager Southern Wake Hospital
Fuquay-Varina, NC
January 12, 1995
Dear Dr. Kessler, As a doctor you constantly work to prevent illness, injury, and death to others. Because it is now impossible for the blind to determine with certainty the kind of insulin in each vial, dosing and dispensing errors occur. Please make needed changes in insulin vial shapes to help prevent misdosage. It's a cheap, small thing to do in order to prevent severe illness and death. Please hear our call for help.
Sincerely,
Blanche Schroeder
Virginia, MN
January 17, 1995
Dear Dr. Kessler: Our agency serves blind and visually impaired persons in the metropolitan Atlanta area and throughout the state of Georgia. A significant number of our clients have diabetes and have lost their vision as a result of this disease. The goal for all of our clients is to assist them in attaining independence with dignity, and to remain productive citizens in their communities. Over the past several years, concern has been evident nationally within the diabetic and visually impaired community over the vital need for appropriate identification of insulin vials. We have followed correspondence and reports through various publications such as the Voice of the Diabetic, published by the Diabetics Division of the National Federation of the Blind, and publications from the American Diabetes Educators organizations. Within these publications were copies of correspondence to and/or from Eli Lilly and Company, Novo Nordisk, Ed Bryant, President of the Diabetics Division of the National Federation of the Blind, and representatives of the Food and Drug Administration. Our agency would like to support the efforts thus far in changing the current packaging, labeling, and shape of insulin vials. In addition, we would like to reiterate the concerns that large print and color coding insulin vials is not adequate for most blind and visually impaired persons with diabetes. We support suggestions such as different vial shapes and large, tactile, geometric shapes for distinguishing different durations and types of insulin. Of course these will need to be uniform changes applied to all pharmaceutical companies who make and distribute insulin products. We would also like to see consumer representation when changes are considered. We hope that your agency will do whatever necessary to expedite the proposed changes needed to assist blind and visually impaired persons with diabetes in caring for themselves safely and independently. We feel that the potential danger and possible fatal results of confusing insulin types has been made clear in previous correspondence referenced above. We hope that the lives and health of visually impaired and blind persons with diabetes will be considered when weighing the cost of such changes in insulin packaging. Thank you for your time and consideration regarding the proposed changes that are so urgently needed.
Nancy Miller
Diabetes Education and Management Specialist
W. Scott McCall
Executive Director
Center for the Visually Impaired
Atlanta, GA
January 20, 1995
Dear Dr. Kessler, This letter voices the strongest support possible for the campaign being conducted by the National Federation of the Blind to incorporate tactile cues in insulin vial packaging. As you are aware, in the not too distant past, the bottle shapes varied for each type of insulin. This allowed blind diabetics an easy way to determine which insulin was in hand. Now, with all insulin vials indistinguishable from one another except by reading the label, the ability of blind diabetics to self manage their care is impaired, making medication errors during insulin preparation more likely. For safety reasons, FDA should change necessary regulations to insist that tactile cues be reinstituted. The Institute for Safe Medication Practices is an FDA MedWatch partner. ISMP cooperates with both USP and FDA by providing independent practitioner review of all medication errors submitted to the USP Medication Errors Reporting Program. In addition, under an FOI request, we obtain and review all FDA MedWatch reports coded as medication errors. Material from error reports is used to provide education about medication safety to nearly two million nurses and pharmacists monthly through various professional journals and newsletters. If it would be helpful, we would ask our readers to support regulatory changes to allow blind diabetics a better way to differentiate insulin types and reduce potential for user error. I will be in touch with pharmacy officer Tom McGinnis of the FDA Medicine Staff to follow up on this situation.
Sincerely yours,
Michael R. Cohen, MS, FASHP President
Institute for Safe Medication Practices
Warminister, PA
February 20, 1995
Dear Dr. Kessler: Since the discovery of insulin more than seventy years ago, insulin manufacturers have worked continually to provide the best insulin product possible. Today, through the use of advanced technology, the purest insulins ever are available for use by persons with diabetes and by health care providers. The manufacturers need to go one step further in their service to the large diabetes population Ä the insulin packaging needs to be user-friendly for visually impaired people with diabetes. Diabetes is the leading cause of new blindness in the United States. It is responsible for about 12,000 cases of legal blindness each year with an even greater number who develop severe visual impairment. These are insulin-taking diabetics! There are many adaptive products on the market to assist a visually impaired person with daily diabetes cares Ä devices to help them measure and mix insulin, audible insulin pumps, "talking" blood glucose meters Ä to name a few. The missing link in providing the means for accurate insulin dosing and preparation is a standard way for the visually impaired person to correctly identify the type of insulin being used. The problem is the current labeling policies which provide no alternative to reading the label. At present, despite all the adaptive devices available, visually impaired persons still have to use tactile cues such as rubber bands or tape on certain insulin vials to identify which type they are using.
Others have had to make arrangements for relatives, neighbors, etc. to prepare their insulin Ä often an inconvenience for all involved. Worse yet, there are some who must enter an assisted living facility, because they can not safely manage their insulin needs due to their vision loss. The bottom line for all directly and indirectly involved is the assurance that the visually impaired person can safely prepare and administer insulin. Insulin accuracy plays a major role in helping to achieve better diabetes control Ä a goal for all with diabetes to reduce the risk and/or severity of additional complications. The Minneapolis-St. Paul Diabetes Educators group, a chapter of the American Association of Diabetes Educators, has written both Eli Lilly and Company and Novo Nordisk Pharmaceuticals, the primary manufacturers of insulin, regarding our serious concern for appropriate labeling of insulins for use by visually impaired persons with diabetes. We have received replies from both companies acknowledging the need for improving insulin labeling and the varying degrees of effort to do so. Now, your support and influence is needed in modifying regulations and/or policies regarding packaging and use of tactile cues to be incorporated into the insulin vial. We urge your earnest consideration of this important request which directly impacts the lives of so many persons with diabetes. Please direct your response to our request to our chapter president: Tammy Scott, c/o Health East. ... You may also contact her if you would like additional information pertinent to our request.
Thank you.
The Minneapolis-St. Paul Diabetes Educators
American Association of Diabetes Educators
St. Paul, MN
I have received a great deal of comments and correspondence on insulin container configurations. Consensus is overwhelming Ä vial shapes need to be changed! If you are interested in diabetes and have any input on this matter, please make your thoughts known to FDA Commissioner Kessler at the following address and please send me a copy at the Voice office:
Dr. David A. Kessler, Commissioner Food and Drug Administration 5600 Fishers Lane Rockville, MD 20857
by Amy Walters
Although I have been diabetic since the age of six, I was never informed of the possible complications of diabetes. I was diagnosed with diabetic retinopathy and glaucoma when I was 21. Doctors told me then that I would never lose my sight completely. Much to their shock, and mine, I lost all my sight.
Another ramification of diabetes, of which I had no inkling, was renal failure. When my creatinine level began increasing in 1989, the subjects of dialysis and transplantation were discussed. At that time anti-hypertensive medication was prescribed and I was told to follow a low-protein diet. Even though the advice bought a little time, I knew from the elevating numbers on lab results that decisions would soon have to be made regarding available options.
The idea of having a kidney transplant sounded ghoulish, like a modern-day Frankenstein. I did not particularly relish the thought of having a stranger's body part in me. I even considered not having anything done at all and just live with what time I had remaining without high-tech medical miracles being performed on me.
Up to this point, I had been feeling well. However, a bout with the flu caused dehydration so I was hospitalized. It had sapped my energy and left me feeling as though I could sleep all day. Also, my creatinine level skyrocketed to the point where it became time for a graft. Because my veins weren't that good, an A-V graft (a piece of plastic tubing inserted beneath the skin on the inside of the forearm) would enable me to undergo dialysis. When I realized life was slipping away, it became more precious to me. I wanted to go on living. Yet, I wondered what life would be like after dialysis, transplantation, and whatever else would happen to me. Would I become an invalid so bothered by side effects of those powerful anti-rejection drugs that my life would be, in effect, no life at all?
Fortunately, I retained some kidney function, so dialysis turned out not to be that bad despite the stories I had heard. For five months prior to the operation, I went twice a week for two and a half hours at a stretch. Once dialysis began, I was amazed at the amount of energy I had. Dialysis is not something I would choose to continue for the rest of my life, but it helped me over the hump.
Initially, a friend was going to give me one of her kidneys, but a better match was found November 16, 1989. I'll never forget the date nor that call. Once I reached the hospital, I learned I had almost a perfect match. The only way it could have been closer was if the kidney had come from an identical twin.
Perhaps it was the closeness of the match or the experimental drug I was taking to offset the need for a high dosage of Cyclosporine that prevented me from having any trouble with rejection. Even now, I take minimal amounts of Cyclosporine, along with two other immuno-suppressive medications Ä a drug for high blood pressure and, of course, insulin.
Things certainly have been good since surgery. I feel I have been given a whole new lease on life. Instead of associating the transplanted kidney with a monster in some movie, I look at it now as a special gift from a very generous person who thought of someone else in a time of grief, and, I'm not a dependent, sickly invalid.
Approximately five months after receiving my new kidney, I returned to New Jersey to obtain another Seeing Eye dog. The funny part about that was when I received my first dog, I'd had an appendectomy only two months before. I had to show the on-duty nurse my scar in order for her to believe that I was ready for training so soon after surgery. Would you believe the same nurse was still there? Was she ever surprised to see my latest scar acquisition! That odd coincidence is only part of my good news. For over a year now I've been working for the Social Security Administration, and last April I moved into my very own apartment. It was a big step for me because I've always lived with someone else Ä my parents, roommates, my former husband. Now, I have my own space in my own apartment.
Life truly is a gift which one should make the most of each day. Life is also something to be shared, as is done by the people who say "yes" to organ donation. Without that special person's thoughtfulness, who knows where I'd be today? I'm very thankful I'm still around!
Are you at risk for diabetes? Take the adjoining quiz and find out. Here's the scoring:
3-5 points:
If you scored 3-5 points, you are probably at low risk for diabetes. But don't just forget about the risk Ä especially if you have a family history, are over 30, overweight, or are a Black American, Hispanic, or American Indian.
What to do next:
Learn and know the symptoms of diabetes Ä excessive thirst, frequent urination, extreme fatigue, unexplained weight loss, blurred vision. If you experience any of them, contact your doctor for further testing.
More than 5 points:
If you scored more than 5 points, you may be at high risk for diabetes. You may even already have diabetes.
What do do next:
See your doctor as soon as possible. Find out if you have diabetes. Even if you don't have diabetes, learn and know the symptoms. If you experience any of the symptoms in the future, see your doctor immediately.
Reprinted with permission from the American Diabetes Association. Copyright 1993 by the American Diabetes Association, Inc. All rights reserved.
Diabetes Risk Test
Write in the points next to each statement that is true for you. If a statement is not true for you, put a zero. Total the score for all statements. Match your total figure with the scoring instructions below.
1. I have been experiencing one or more of the following symptoms on a regular basis:
Excessive thirst YES 3______
Frequent urination YES 3______
Extreme fatigue YES 1______
Unexplained weight loss YES 3______
Blurry vision from time to time YES 2______
2. I am over 30 years old YES 1______
3. My weight is equal to or above that listed in the weight chart YES 2______
4. I am a woman who has had a baby weighing more than nine pounds at birth YES 2______
5. I am of American Indian descent YES 1______
6. I am of Hispanic or Black American descent YES 1______
7. I have a parent with diabetes YES 1______
8. I have a brother or sister with diabetes YES 2______ TOTAL______
NOTE: This test is meant to educate and make you aware of the serious risk of diabetes. Only a medical doctor can determine if you do have diabetes.
The charts below show weights that are 20 percent heavier than what is recommended for both men and women with a medium frame. If your weight is above the amount shown for your height, you may be at risk for developing diabetes.
Weight chart for women (shows 20% over maximum
ideal weights)
Height Weight (without shoes)(without clothing) Feet Inches Pounds
4 9 127
4 10 131
4 11 134
5 0 138
5 1 142
5 2 146
5 3 151
5 4 157
5 5 162
5 6 167
5 7 172
5 8 176
5 9 181
5 10 186
The American Diabetes Association urges all pregnant women to be tested for diabetes between the 24th and 28th weeks of pregnancy.
Weight chart for men (shows 20% over maximum ideal
weights)
Height Weight (without shoes)(without clothing) Feet Inches Pounds
5' 1" 146
5 2 151
5 3 155
5 4 158
5 5 163
5 6 168
5 7 174
5 8 179
5 9 184
5 10 190
5 11 196
6 0 202
6 1 208
6 2 214
6 3 220
This memorandum explains the need to work with Congress in serving the blind. For more information please contact Mr. James Gashel, Director of Governmental Affairs, National Federation of the Blind, 1800 Johnson Street, Baltimore, MD 21230; telephone: (410) 659-9314.
If item seven in the Contract with America is enacted as proposed, a provision in the Social Security Act for exempting earnings of blind people and senior citizens to the same extent will be repealed. The amount of earnings allowed without penalty for blind persons will remain where it is now, with only marginal, future annual adjustments being made. Meanwhile, the earnings exemption for seniors will be raised by five mandated annual increases in order to reach $30,000 in the year 2000. The reason for doing this is to diminish the disincentive of the earnings limit and to increase work and productivity. By the same reasoning the higher earnings exemption should also apply to blind people, who like the seniors are penalized for working.
In voting on the Contract with America, Congress must decide whether work incentives for blind people are less important than raising the earnings exemption standard for seniors to $30,000. Both goals have identical merit and should be given identical weight. Work, productivity, and the opportunity for more people to pay taxes would be the result. Accordingly, blind persons are asking that their need to achieve economic independence through work not be set aside.
DESCRIPTION OF EXISTING LAW
Under an amendment authorized by Congressman Archer in 1977, blind people who have not attained age 65 are affected by the same earnings limit that the Social Security Act imposes on age 65 retirees. Mr. Archer's amendment, establishing an identical earnings exemption standard for blind people and retirees, has been law for almost 20 years. Blindness and retirement age are both defined eligibility conditions in section 216 of the Social Security Act. The disability test Ä the inability to engage in Substantial Gainful Activity Ä is not used to determine whether an individual meets the blindness criteria in the Social Security Act. Only medical evidence is used for this determination.
CONTRACT WITH AMERICA: PROPOSED CHANGES
Item seven in the Contract with America is a bill known as the Senior Citizens' Equity Act Ä H.R. 8, by Congressman Jim Bunning, and S. 30, by Senator John McCain. The modifications to the earnings limit being proposed include five mandated upward adjustments in the exempt amount to reach $30,000 of annual earnings beginning in the year 2000. Section 101(b) of the bill would specifically exclude blind people from the mandated adjustments. The exclusion departs from existing law. The National Federation of the Blind (along with every other organization having interests in the blindness field) strongly opposes this change. The provision would create an earnings limit for blind people which is far more stringent that the earnings limit for age 65 retirees Ä a serious change in direction which will have far-reaching and harmful work disincentive effects upon the blind.
NEED TO REMOVE WORK DISINCENTIVES
Continuing the existing policy by mandating the adjustments in the earnings limit for blind people as well as for age 65 retirees will assure that an estimated 104,300 blind beneficiaries will receive a powerful work incentive. Most blind people could then not lose financially by working. The mandated earnings limit changes, if made applicable to blind people, would be cost-beneficial since, among those of working age, 70 percent are currently unemployed or underemployed. Most of them are already beneficiaries. At present their earnings must be strictly limited to $940.00 per month. When earnings do exceed this exempt amount the entire sum paid to a primary beneficiary and dependents is abruptly withdrawn after a trial work period. When a blind person finds work, there is absolutely no assurance that earnings will replace the amount of lost disability benefits after taxes and work expenses are paid. Usually they do not. Therefore, few of the 104,300 beneficiaries can actually afford to attempt substantial work. Those who do will often sacrifice income and will certainly sacrifice the security they have from the automatic receipt of a monthly check. This group of beneficiaries Ä people of working age who are blind Ä must not be forgotten as the debate proceeds toward modifying the Social Security retirement test. Just as with hundreds of thousands of seniors, their positive response to the higher amounts of earnings allowed will bring additional revenues into the Social Security trust funds.
ACTION REQUESTED
In taking a position on legislation to approve item seven in the Contract with America, each member of Congress should vote to ensure that equity in the work incentive policies of the bill applies, as under current law, to senior citizens and blind people alike. To achieve this, we ask you actively to promote striking the exclusionary provision Ä section 101(b) Ä of the Senior Citizens' Equity Act so that an identical earnings exemption standard for blind people and retirees alike Ä the policy of the present law Ä is maintained.
To receive a free copy of the presentation Mr. Gashel made to the United States House of Representatives Subcommittee on Social Security, please contact: Mr. James Gashel, Director of Governmental Affairs, National Federation of the Blind, 1800 Johnson Street, Baltimore, MD 21230; telephone: (410) 659-9314.
by Diana W. Guthrie, PhD, FAAN, CDE
Dr. Guthrie is a professor at the University of Kansas School of Medicine-Wichita. She has a doctorate in Philosophy and Social Change and works in behavioral psychology. In addition, Dr. Guthrie has her own diabetes clinic.
Yeast infections, usually Candida, cause a terrible itching. Women who have a change in the pH of the vaginal tissues are more susceptible to a yeast infection. A yeast infection is accompanied by a yellow or white cheesy discharge which is usually odorless (most other vaginal infections have an odor to the discharge). This type of infection is most likely not sexually transmitted. When the blood sugar is high, there is a greater chance for this and other vaginal infections to occur. When a vaginal infection occurs, there is a greater chance that the blood sugar will go higher than it presently might be. Pain on intercourse is also likely to occur.
In a study of 203 women with diabetes, Candida albicans was isolated from 12.8% of all patients. This disease showed a significant association with the woman who had vaginal and external vaginal itching. In the particular population studied, of all the yeast infections identified, Candida glabrata was found in 50% of the cases and Candida albicans next (36.1% of the cases). Treatment in the United States has more recently become easier to obtain.
Antifungal medications are now available in over-the-counter preparations in creams or suppositories. A person with diabetes must be wise in choosing to use an over-the-counter preparation. First, blood glucose levels must be normalized as much as possible. Second, if the recommended treatment time (i.e., seven days) does not bring the desired results, a physician must be consulted. If the infection is quite severe from the start, it is better to consult a physician and obtain the proper cultures before starting the treatment so that the specific organism(s) is(are) found. It is possible that more than one organism is responsible for the vaginal infection. And third, prevention is best. This means cleanliness (including good personal hygiene, i.e., wiping from front to back), blood sugar control, completing the full length of treatment (i.e, if treated, the suppositories or creams must be used for the full seven-day course of treatment, not just until the symptomatic itching and discharge go away), fruits and vegetables, exercise, and adequate rest should be included as part of the daily life style, and drinking plenty of fluids (preferably water) is a must. Other recommendations are the wearing of cotton rather than nylon underwear. Tight clothing appears to aggravate the itching and also prevents drying air to reach the infected area (eg, the wearing of tight jeans or other tight clothing especially made of tightly woven fabric). Douching is more harmful than helpful. Do not use douches unless recommended by the health professional. Soap and water is better than the use of a feminine hygiene spray. Safe sex must be practiced, especially if there is more than one partner. And remember, if the blood sugars are out of control, there will be a greater chance that the women will develop a yeast infection or other types of vaginal infection.
There is a greater chance that a vaginal infection will occur if the person is pregnant, taking oral contraceptive drugs, or menopausal. All these three occurrences lead to the possibility of a change in the pH of the vaginal tissues, so dietary intake is very important, even though a specific approach to dietary intake is questioned by some. Again, prevention is the best approach.
From the Editor: I have received much communication regarding insulin vial configuration from health care providers and lay-persons, with unanimous consensus that different types of insulins should be packaged in differently shaped vials for greater safety. If vials were shaped differently, both blind and sighted diabetics could identify types of insulin by touch. Container design changes would definitely help the blind. Moreover, such changes would also benefit the sighted. The following letters support this premise.
December 23, 1994
Dear Ed, Just a note to thank you for helping with the insulin vial shapes and markings. From my letter to the Commissioner, Dr. Kessler, you can see what RNs and MDs are facing with the small print on the vials. Sometimes the print is so tiny, I use a magnifying glass to identify the words. It is really unsafe and I blame drug companies for not being creative enough to overcome this problem. I have diabetes type II and I appreciate very much what you are doing for us. I am not the only nurse who complains of this matter Ä but I am one of the more vocal. I really appreciate this opportunity to write to the Food and Drug Administration to voice my complaint Ä you've made it very convenient for me. I will give the drug company credit for using color codings on some drugs Ä it can only help the sighted Ä right?
Again, appreciatively, Clara Lipe, RN La Palma, CA
Published in a past Voice, the following is self explanatory. Due to its clarity, it is being recarried.
February 2, 1993
Dear Mr. Bryant: A recent issue of Voice of the Diabetic was forwarded to me by one of your readers. The article about insulin vial configurations caught my eye. Our institute has an agreement with the United Sates Pharmacopeia, Inc. to operate the Medication Error Reporting Program (USP MERP), a system used by health care practitioners, to voluntarily and confidentially report mistakes they or their colleagues have made. The idea is to educate one another about medical errors in the hope that such knowledge will help reduce the incidence. We are in support of your proposal to change insulin vial configurations in order to reduce dosage errors. This would be helpful to health care practitioners as well as diabetic patients. Unfortunately, mistakes in choosing proper containers are occasionally made by practitioners, so we too could use the help that tactile features would provide. For example, we have had mix-ups reported where vials of regular insulin were improperly placed into an NPH cardboard outer package and later used accidentally for NPH. While we recommend that the cardboard box be discarded when a new vial is opened, shaping the various insulin vials differently would add an important layer of safety. We are aware of other medication containers that provide tactile barriers against error. The Burroughs Wellcome Company packages the muscle relaxant Tracrium in a hexagonally shaped vial. Since this drug is used to induce complete paralysis during surgery, accidentally giving it to someone who is not simultaneously receiving artificial ventilation will cause respiratory arrest. The odd shape reduces the possibility that Tracrium will ever be confused with another drug. Thank you for your efforts to improve the level of safety of insulin administration. Please let me know if I can be of assistance.
Sincerely yours, Michael Cohen, MS, FASHP President Institute for Safe Medication Practices, Inc. Huntingdon Valley, PAn
by Joseph Tripodi, D.O. and Robert Burakoff, M.D.
From the Voice Editor: Although the following article is highly technical, it provides valuable information for laypersons as well as health professionals. For people with diabetes who are experiencing problems with digestion, this information may be beneficial. Moreover, many physicians will be able to better serve patients after reviewing this article.
If you are a diabetic, I urge you to share this report with your doctor. He or she may be enlightened and better able to serve patients.
Gastroparesis is a motility disorder that results in delayed emptying of gastric contents without evidence of outlet obstruction. Diabetes mellitus remains one of the most common conditions associated with delayed gastric emptying, especially in those patients with known autonomic neuropathies. Providing relief of clinical symptoms while maintaining adequate nutrition and good blood glucose control is a challenging problem. Advances in the understanding of gastric motility and improvements in diagnostic techniques have aided the clinician in making the diagnosis. The recently developed drug therapies have dramatically altered the treatment strategy.
Pathophysiology
The stomach can be considered in two physiologic parts: proximal (fundus and body) and distal (lower body and antrum).
The proximal stomach acts as a reservoir for food and adaptively dilates in response to gastric distention. This adaptation occurs by inhibition of the basal gastric contraction and is abolished after vagotomy is performed.
The distal stomach acts to mix and grind solid food to a chymelike consistency (<2 mm in size). Distal gastric contractions are regulated by a pacemaker found on the greater curve of the upper body. The pacemaker generates depolarizing events that are propagated to the pylorus cyclically at a rate of 3-4 per minute. Action potentials are stimulated on top of these depolarizing events by the presence of food and neurotransmitters. Action potentials cause muscular contractions that increase in amplitude and velocity as they move distally. As the peristaltic wave approaches the antrum, the pylorus closes, causing mixing and grinding of solid food. Solids are finally emptied after being altered to a chymelike consistency. Liquids are emptied down a pressure gradient created by the basal tonic pressure in the stomach. Indigestible solid material is emptied by a fasting electro-mechanical activity known as the migrating motor complex, which occurs every two hours. Factors which are important in the rate of gastric emptying are summarized in Figure 1. In diabetes, various abnormalities can account for abnormal gastric emptying. These abnormalities include increased basal pyloric tone, the absence of the interdigestive migrating motor complexes, and the presence of antroduodenal incoordination. Some studies in people with diabetes have shown that morphological damage to the vagus nerve and elevated blood glucose levels may be responsible for delayed gastric emptying.
Clinical Presentation
Gastroparesis is usually a complication of long-standing insulin-dependent diabetes. It reportedly effects 20% to 30% of patients with diabetes mellitus, with the average duration of diabetes prior to the onset of symptomatic gastroparesis being slightly more than 18 years. However, using modern diagnostic techniques, abnormal gastric motility can be detected in a greater number of patients and often before clinical symptoms are apparent.
Liquids usually empty from the stomach quickly in the first 15 minutes in the majority of diabetic patients. This is due to the lack of the normal adaptive relaxation of the proximal stomach. It is the ingestion of solid foods that usually produces gastrointestinal symptoms in most diabetics with gastroparesis. Indigestible food matter retained in the stomach can lead to the formation of bezoars due to the lack of migrating motor complexes. Symptoms are often nonspecific and do not correlate well with the degree of delay in gastric emptying. Epigastric pain, nausea, vomiting, early satiety, belching, postprandial fullness, and weight loss are among the symptoms that suggest the diagnosis. Gastroparesis is usually associated with other evidence of autonomic dysfunction such as postural hypotension, abnormal response to the Valsalva maneuver, bladder dysfunction, and impotence. Constipation and diarrhea may also be found. The presence of a succession splash over the left upper quadrant on physical exam may indicate a problem with gastric emptying, but it is neither sensitive nor specific for the diagnosis of diabetic gastroparesis.
A careful search should be conducted to determine the etiology of gastroparesis (Figure 2). Upper-gastrointestinal endoscopy is recommended as the primary diagnostic procedure for this purpose. Endoscopy defines anatomic gastric outlet obstruction and can exclude morphological lesions, including ulcers or tumors. Endoscopy may also be therapeutic in the presence of bezoars or retained food particles. Endoscopy is not useful, however, for detecting motility disorders.
Gastric emptying can be measured by intubative techniques, radiological techniques, or radioisotopic techniques. The saline load test is an intubative technique that requires the insertion of a nasogastric tube and instillation of 750 cc of saline into the stomach. Recovery of more than 200 cc of fluid 30 minutes later is indicative of gastric retention. Though easy to perform, the test can only assess liquid emptying and therefore is of limited value in patients with diabetic gastroparesis as liquid emptying is usually normal in these patients. Radiological techniques assess the emptying of liquid barium sulfate or radiopaque solid meals. Unfortunately, only the time of complete emptying of the stomach can be measured, as residual barium cannot be accurately quantified. Furthermore, barium-impregnated food may not reflect solid emptying, as the barium granules rapidly disassociate into a liquid phase.
The radioisotope method using external scanning has proven to be a reliable, non-invasive technique for quantitatively measuring gastric emptying. The most widely used radioisotope is technetium 99m (99m Tc). Technetium 99m bound to sulfur colloid is injected into a live chicken. Ninety percent of the colloid is taken up by the liver. The liver is cooked and then ingested by the patient on an empty stomach as a test meal. In our hospital, the meal consists of 7.5 oz. of untagged beef stew and 20 g of tagged chicken liver, delivering a total dose of 200eCi. The radiation exposure is considered well within the tolerable range. External scanning is begun at 1 minute and recorded continuously for 2 hours for solids and 20 minutes for liquids. A gastric-emptying profile is computer-generated, and abnormal emptying of a solid meal is defined as greater than 50% retention after 120 minutes. It is also possible to record both liquid-phase and solid-phase gastric emptying simultaneously using dual radioisotopes. This diagnostic technique also allows assessment of response to prokinetic drugs. Most authorities now agree that the radioisotope gastric-emptying scan is essential to secure the diagnosis of gastroparesis. Measurements of gastric impedance using cutaneous electrodes or the use of real-time ultrasound have yet to achieve a role in clinical practice.
Treatment
The main goal of therapy for gastroparesis is to promote gastric emptying of solid food. First, treatment should be directed toward correction of fluid and electrolyte imbalance. Large meals should be replaced by small meals, which are better tolerated in gastroparesis. Indigestible foods, such as green vegetables or other high-fiber foods, may induce postprandial symptoms and should be avoided. Associated factors contributing to delayed gastric emptying should be treated; these include concomitant peptic ulcer disease and reflux esophagitis. The administration of anticholinergic and narcotic drugs should be discontinued if possible. Glucose levels above 200 mg/dl have been shown to delay gastric emptying, so better glucose control may be beneficial. Drug therapy remains the mainstay of treatment for this disorder, and several prokinetic drugs have recently been approved to expand the pharmacologic armamentarium.
Bethanechol, a cholinergic agent, was used initially for the treatment of gastroparesis because earlier studies showed that it increased the frequency and amplitude of gastric contractions, but radionuclide studies failed to confirm accelerated transit times. The inconsistent data and an unfavorable side-effect profile has led many physicians to abandon its use as a prokinetic agent.
Metoclopramide, a procainamide derivative, has strong cholinergic and antidopaminergic effects. The drug significantly accelerates gastric emptying by inhibiting fundic receptive relaxation and coordinating gastric, duodenal, and pyloric motility. In diabetic gastroparesis, the drug also activates peristalsis by initiating previously absent interdigestive migrating motor complexes. Metoclopramide exhibits an antiemetic effect by passing through the blood-brain barrier and directly influencing the chemotactic trigger zone. Therapy with metoclopramide has been shown to evoke symptomatic relief of diabetic gastroparesis even without simultaneous improvement in gastric emptying. This improvement may be explained by its central effects on the chemotactic trigger zone. The usual dosage is 10 mg orally four times a day, given approximately 15-30 minutes before each meal and at bedtime. Improved gastric emptying of solids and liquids in diabetic gastroparesis has also been demonstrated with intravenous metoclopramide at similar dosages. Severe gastroparesis unresponsive to oral metoclopramide has been reported to respond to rectal administration. Although metoclopramide is effective initially, there are two uncontrolled studies on a small number of patients that indicate the therapeutic effect may partly disappear with long-term therapy. Further investigation needs to be done before a final recommendation can be made regarding long-term treatment. Side effects (Figure 3) occur in 10%-20% of patients and are severe in 1%. Metoclopramide should not be used in patients with intestinal obstruction, perforation or hemorrhage, Parkinsonism, or epilepsy.
Domperidone, a benzimidazole derivative, is a powerful prokinetic agent that acts by blocking dopamine inhibition of acetylcholine release at dopamine D2 receptors located on postganglionic cholinergic neurons. Short-term therapy with intravenous or oral domperidone improves gastric emptying of liquids and solids, but long-term administration enhances liquid emptying only. While gastric emptying of solids appears unchanged with long-term therapy, patients do have some symptomatic relief. The most commonly studied dose is 20 mg taken orally four times per day. However, dosages as low as 10 mg four times a day were successful in improving symptoms in patients with diabetic gastroparesis that was unresponsive to metoclopramide. Intravenous administration has been associated with cardiac arrhythmias and is not recommended. A major advantage of the drug is that it does not cross the blood-brain barrier and therefore has fewer CNS side effects. However 10% to 15% of patients develop side effects related to drug-induced elevation of prolactin levels. Other side effects include dry mouth, transient skin rash, headache, diarrhea, and nervousness. Although domperidone has been used successfully in Canada, at this time it is not currently approved by the FDA for use in the United States.
Cisapride, a substituted piperidinyl benzamide, is a new class of drug that does not have antidopaminergic properties but is believed to increase gastric motility by enhancing the release of acetylcholine from the myenteric plexus in the gut. In vitro studies demonstrate that cisapride as well as metoclopramide have 5-hydroxytryptamine (5-HT4) receptor agonist activity, and this may in part explain their prokinetic activity. In healthy volunteers, cisapride has been found to increase antral and duodenal contractions and improve antroduodenal coordination. Studies in people with diabetes illustrate that the effects of cisapride (both oral and IV) are dose related and correlate well with plasma drug levels. The improvement of solid-phase gastric emptying with cisapride was greater than that with metoclopramide at similar doses. In contrast to metoclopramide and domperidone, long-term administration of cisapride has been associated with improved gastric emptying and symptom control for greater than one year. Two placebo-controlled double-blind trials conducted exclusively on patients with diabetic gastroparesis have demonstrated accelerated gastric emptying and improved symptoms. However, in two other double-blind crossover placebo-controlled studies, there was no significant difference in gastric emptying or symptom improvement, but there was a trend toward decreased epigastric fullness and less diarrhea. These differences may reflect the limited number of patients studied or the presence of underlying medical problems that may have masked the therapeutic benefits. Perhaps higher dosages may be necessary to achieve sufficient drug levels for a desired clinical effect. In the above-mentioned studies, cisapride did not produce a significant change in glycemic control, and adverse effects were rarely reported (Figure 3). Despite the appearances of effectiveness and the narrow side-effect profile, cisapride has not been approved by the FDA for the treatment of diabetic gastroparesis. In fact, its only approved use is for symptomatic treatment of nocturnal heartburn due to gastro-esophageal reflux disease.
Erythromycin, a macrolide antibiotic, has been found to stimulate gastric motility by binding to motilin receptors, which are found mainly in the gastric antrum and proximal duodenum. This effect is related to its molecular structure and not its antibiotic activity, a fact that may be helpful in developing newer prokinetic agents without antimicrobial activity. One study showed that 200 mg of erythromycin ethylsuccinate given intravenously postprandially improved gastric emptying of radiolabeled liquids and solids in diabetic gastroparesis. This effect persisted after four weeks of oral therapy with 250 mg erythromycin ethylsuccinate taken three times a day 30 minutes before meals. A more recent study confirmed these findings using an oral dose of 500 mg four times a day one-half hour before meals and before bedtime. However, a significant improvement in clinical symptoms was not demonstrated, perhaps due to the small sample size studied. Thirty percent of subjects could not tolerate this dose due to side effects but tolerated a lower dose of 250 mg or 125 mg four times daily, thus supporting the need for individual titration of dosage and frequency. An oral suspension may be the preferred form of administration because it allows the greatest dosing flexibility. The most common side effects are abdominal pain, nausea, vomiting, and diarrhea. The potential for a reversible chemical hepatitis with the estolate form would favor the use of the ethylsuccinate form of erythromycin. Serious liver injury was not seen in the studies mentioned above, but careful observation for interactions with drugs metabolized by the P450 system should be performed to ensure safety. The role for long-term treatment with erythromycin has not been proven. In fact, in vitro work with rabbits showed that motilin receptors may be down-regulated by continuous stimulation with erythromycin. There have been no published trials comparing erythromycin to other prokinetic agents. Surgical therapy employing pyloroplasty, gastric resection,and gastrojejunostomy have been tried. These are usually reserved for severe refractory gastroparesis. Roux-en-Y gastrectomy has been reported to have some success when conservative surgical procedures have failed. An endoscopically placed double-lumen gastrostomy tube (one lumen in the duodenum for feeding and other lumen in the gastric fundus for decompression) has also been successful in selected cases.
Conclusion
Gastroparesis is a common complication of diabetes mellitus. The clinical presentation is often nonspecific and does not correlate with pathology. The radionuclide gastric-emptying scan is the best test to confirm the diagnosis. Although metoclopramide is the only drug approved for the treatment of diabetic gastroparesis, cisapride, domperidone, and erythromycin may be logical alternatives when efficacy is limited or when side effects prevent the use of metoclopramide. The combination of agents with different mechanisms of action may also play a future role in the treatment strategy. Further studies are needed to determine the role of these drugs in the long-term management of diabetic gastroparesis.
Dr. Tripodi is a Gastroenterology Fellow with the Department of Gastroenterology and Nutrition, Winthrop-University Hospital, Mineola, New York. Dr. Burakoff is Chief of the Division of Gastroenterology at the same institution.
(Note: This article appeared in Practical Diabetology. Reprinted with permission.)
((( above story with 3 charts )))
Figure 1.
Factors that affect gastric emptying
Factors that increase gastric emptying ù Volume (liquids) ù Food composition: Neutral pH Iso-osmolar Calorically inert Factors that decrease gastric emptying ù Acidity ù Hyperosmolarity ù Fat ù Amino acids
Figure 2.
Differential diagnosis of gastroparesis
Mechanical Pyloric stenosis due to ulcers Obstructing gastric cancer Prolapsing gastric polyp Infantile and adult hypertrophic pyloric stenosis
Functional ù Metabolic Diabetic gastroparesis Hypothyroidism Uremia Pregnancy ù Medications Anticholinergic drugs Narcotics l-dopa Tricyclics ù Infiltrative diseases Amyloid Gastric malignancy ù Neuromuscular Dermatomyositis Muscular dystrophy Myotonic dystrophy Scleroderma ù Psychiatric Anorexia nervosa Bulimia ù Surgery related Vagotomy Gastric resection ù Idiopathic Gastric dysrhythmias
Figure 3.
Side effects of gastroparesis medications
Metoclopramide Drowsiness Restlessness Anxiety Constipation Diarrhea Dystonic reactions (1%) Tremor Rigidity Akinesia Raises prolactin Domperidone Raises prolactin Nervousness Headache Dry mouth Diarrhea Erythromycin GI upset Hepatotoxicity Rash Reversible hearing loss Cisapride Abdominal cramps Diarrhea Headache Dizziness
by Wesley W. Wilson, M.D.
NOTE: If you have any questions for "Ask the Doctor," please send them to the Voice editorial office. The only questions Dr. Wilson will be able to answer are the ones used in this column.
Wesley Wilson, M.D. is an Internal Medicine practicioner at the Western Montana Clinic in Missoula, Montana. Dr. Wilson was diagnosed with type 1 diabetes in 1956, during his second year of medical school.
Q: I have been experiencing needle-like pains in my feet and lower legs. My doctor says he thinks the pain is caused by diabetic neuropathy, and he knows of nothing I can do about it. Is he correct? Is there any medication I can use to help me deal with this pain?
A: I'm sorry but I will have to answer your question with a typical doctor's response that "it depends, more evaluation is needed."
Diabetic neuropathy is a frequent complication of diabetes. Like most diabetic complications, it usually occurs after years of diabetes and may manifest itself in numerous different ways, such as: pins and needles sensation, burning, or sharp shooting pains. Sometimes, neuropathy takes the form of lack of sensation, or a feeling of numbness. As the term suggests, neuropathy is pathology or abnormality in nerve function. The symptoms a person may have depends upon which nerves are affected, the degree of abnormality in the nerve, and whether there are other complicating problems.
Probably the most frequent symptoms of diabetic neuropathy are burning, tingling, or numbness in the toes and feet. These symptoms usually begin in the toes and often progress to spread the abnormal sensation up the leg. Occasionally, the patient may experience similar symptoms in the fingers and hands. It is felt that the longer the nerve fiber, the more injury to nerve structure can occur. As the longest nerve fibers in the body stretch from the spinal cord in the small of the back all the way to the toes, they are the first to show abnormal function. If the problem progresses, shorter nerves are injured as well, causing symptoms closer to the spinal cord, further up the legs, or in the hands.
Since the sensory nerves seem to be involved early, the first symptoms noticed by the individual may be those of abnormal sensation. Lack of sensation in the toes and feet (especially if coupled with impaired blood flow) is a major problem increasing the risk of injury. The person may actually be unaware of minor injury to the feet, such as ingrown toenails or wounds from tacks. Then, because of poor nutrition of the tissues related to decreased blood flow, there may be diminished ability to fight infection. Lack of warning and lack of defenses are as bad for an individual as for an army.
Any discussion of diabetic neuropathy must include the warning that problems other than diabetes can cause abnormal nerve function. Exposure to some toxins, excessive use of alcohol, poor diet, and especially a low B-12 level can cause impaired nerve function which may resemble diabetic nerve injury. That is the reason physicians often say "it depends" when asked a question such as yours. Usually, careful examination, history evaluation, and testing can help clarify the problem.
It is very important to determine the cause of the nerve abnormality, since nerve cells cannot be replaced if they die. Injury of the nerves is usually irreversible so it is vitally important to discover the cause of nerve injury or damage.
The story of diabetic nerve injury and its treatment is similar to that of other diabetic complications. It is much better to prevent them than it is to treat the complications if they occur. The Diabetes Control and Complication Trial, "DCCT," showed that after only six and a half years the group of diabetics treated with intensive control and hemoglobin A1c averaging about 7% had half as much neurologic abnormality as did the group treated with "ordinary control" and hemoglobin A1c of 9%. It would seem that any reduction in average blood sugar levels has a major payoff with less nerve injury and less progression of nerve injury if it is already present.
Persons who have pancreatic transplantation and who are able to achieve normal blood sugars at all times usually do not have further progress of nerve abnormality. Tight control is difficult to achieve and does not prevent all neuropathy. There is active research to try and determine other means to prevent progressive nerve injury in persons with diabetes and other illnesses. One such technique consists of the administration of drugs called Aldose reductase inhibitors. Studies have shown less nerve injiury and less nerve pathology after administration of these agents to individuals with diabetes, and reduction in neuropathy if they are taken early. These agents are still being tested, and are not yet approved by the Food and Drug Administration for widespread use.
What if you have diabetic neuropathy -- what to do? First be very, very careful to take very good care of your feet. Check shoes for nails or rough spots, never go barefoot, test bath water with your elbow or a thermometer before putting your feet in to prevent burns -- remember your early warning systems are not working!
Symptoms can be improved or reduced by using medication, particularly tricyclic antidepressants, which have been found to be very helpful in relieving the symptoms of nerve injury even though they do not improve nerve function. They often are able to relieve the burning pain and discomfort even though nerve function is still impaired.
Application of capsain, an extract from the peppers that fire up Tabasco sauce, can at times relieve the discomfort of neuropathy, particularly if it is of a burning type.
Conclusions: ú If you have diabetes mellitus, try to control it so as to avoid complications. ú If you do develop complications, try to control the diabetes to slow their progression. ú If you develop neuropathy problems, talk them over with your physician and expect the physician to attempt to determine if the problems are caused by diabetes, or by some other complicating factor. Also expect him to try to help give symptom relief and warnings.
by Allan Nichols
From the Editor: Alan Nichols is chairman of the Amputation Prevention and Treatment Committee established by the Diabetics Division of the National Federation of the Blind. He provides support and information to anyone interested in amputation.
As a diabetic I've had many physical problems over the past thirty years. I became blind in 1978, lost kidney function in 1979 and I've lost both feet to amputation in 1981 and 1987. In this article which focuses on amputation, I send a clear message to readers: learn from my mistakes! Take good care of yourselves! Take good care of yourselves! If your medical staff says to do something, do it! Too often I have ignored good advice and have paid a price for having done so. I pray that my experiences and the information I share will benefit readers. Information learned today may be useful months or years down the road. Again, I implore you to take good care of yourselves!
Following the amputations of both feet, artificial legs enabled me to walk again. New light-weight designs, high technology feet, and other prosthetic improvements made during the last 13 years permit amputees, like myself, to walk and function fairly normally. Even so, complications may arise because stumps do not remain static. Depending on the amount of walking, limbs may shrink or expand over the course of a day, or even in a few hours. Environmental temperature and internal factors can cause problems with the way legs fit and feel. To prevent development of pressure points and sores, I have a constant battle maintaining a comfortable fit. I am usually successful, but on a few occasions, sores develop causing me a great deal of suffering as well as inconvenience.
My first experience with this kind of problem occurred during the 1989 National Federation of the Blind Convention in Denver, Colorado. I remember that particular week because each day the temperature exceeded over 100 degrees. The combination of heat and a great amount of walking caused a sore to develop on my right stump which quickly became infected. Abandoning any plans I had to attend the final day of the convention, I returned home and entered the hospital where the sore was surgically closed and the infection was treated with antibiotics. This sore, which took three months to totally heal, and another major set back six weeks later, put a major crimp in my plans and prevented me from completing my training and the Colorado Center for the Blind.
Four years later in the fall of 1993, my five-year-old artificial legs no longer fit properly and caused another sore to develop in the same place. I needed a new prosthesis, but I had to wait for funding for my new legs to be approved by Wyoming's Vocational Rehabilitation Service. Such funding covered a substantial portion of the cost -- $3600 of over $13,000 -- which wasn't picked up by Medicare. Meanwhile, the sore on my stump increased in size. Funding was eventually approved and I got my new prosthesis, but the skin-deep sore could not heal properly inside the closed environment of my new prosthetic leg. In spite of my best attempts to keep the wound site clean, it slowly worsened. Realizing I'd have to spend a lot of time in a wheel chair or use a walker, as I had done five years earlier, I kept putting off proper treatment; I didn't want to spend any significant time off my feet. Had I known what I know now, I would have gladly taken a month or two off -- off my feet -- instead of spending twice that amount of time to heal the wound later.
About the same time, I began to experience acute pain, due to neuropathy, in the fingertips of my right hand. In fact, my fingers became so uncomfortable that I sought relief at the Wound Care Center in Fort Collins, Colorado. Doctors weren't able to do anything for my hand except prescribe pain medication. I still suffer occasional soreness in my fingers as I await the full resolution of this problem.
However, it is quite a different story with my leg because circulation is much better in my leg than in my hand. The improvement is due to a fairly new treatment, a substance called Procurin. It is manufactured by drawing blood and processing it in the lab to concentrate growth factors. The product is frozen single-application plastic tubes which are stored in a freezer. Thawing takes place on the day of usage. Once liquefied, it must be used within 24 hours. After exposure to room temperature, Procurin must be used within fifteen minutes and the remainder discarded. Because it is made from one's own blood, it can't be used on anyone else. Kept moist with a soaked strip, the wound is covered and sealed with a Vaseline gauze patch. The site is wrapped with loose-fitting gauze and then taped.
The application of Procurin resulted in positive indications that my leg wound had begun to heal. After spending a lot of time off my feet, it became evident that my leg was healing faster. I used my prosthetic leg sparingly and my wound continued to heal steadily. During each trip to the Wound Care Center, the staff and Dr. John Martinez photographed and measured the wound to record healing progress.
At a particularly critical juncture, I made a major mistake which dramatically set back my progress. During the July 1994 convention of the National Federation of the Blind in Detroit, I walked excessively just as I'd done in Denver five years earlier. At home, I usually walked two or three blocks per day, but at the convention, I walked two to three miles per day negotiating my way around the massive hotel complex in Detroit. After four days of constantly walking, my legs let me know in no uncertain terms that I couldn't walk any further. The convention nurse treated my leg with Procurin and noticed that my right leg stump was infected and my left stump had a silver dollar sized blister. I developed a low-grade fever. For the next four days, I traveled around the convention using a wheel chair. Had I been thinking rationally, I would have gone home and had my legs treated immediately. But, being hard-headed, I chose to stay at the convention until the very end.
Back home in Cheyenne, I spent a full week in the hospital while the infection was treated before returning to Fort Collins for additional treatment. Prior to my Detroit trip, the wound had been nearly healed. Now, with the increased depth of the would, healing would take an additional two to three months. While exploring alternative treatments, a plastic surgeon suggested creating a skin flap to cover the injury, but later he said that procedure wouldn't work due to the lack of healthy tissue which keeps the flap viable. With no other treatments available, Dr. Martinez encouraged me to use Procurin again. Along with other predictive tests, the doctor conducted an oxygenation test. A base rate of 30 indicates that a wound has a fair chance of healing. Although the reading was nearly zero around my sore fingers, the area around the wound site on my leg had an initial reading of 43 in May. By July, the reading was an encouraging 53. The text showed that the wound would eventually heal.
In many cases, using Procurin will prevent the need for amputation. Had the treatment been available in 1981, or 1987, I might not have lost my feet. Today, this procedure gives many patients an alternative to amputation. In fact, it can make amputation unnecessary.
In many wound care centers across the United States, treatment includes procedures and techniques which are much less radical. Procurin certainly isn't inexpensive. It is usually tried after all other alternatives are exhausted. The retail cost of the medication is around $80 per dose. Fortunately, for the vast majority of patients including myself, wound care centers often subsidize the costs. About 98 percent of patients pay from $0 to $20 per dose. Cost to the patient depends on income and insurance coverage. In my case, Poudre Valley Hospital in Fort Collins, Colorado covered the expenses and I only paid for the doctor and nurses who followed my progress at the Wound Care Center.
At home, my wound is treated twice each day by home health care nurses. Because Procurin is only effective for about twelve hours, the soaked gauze must be alternated with a saline dressing which, in effect, gives the growth factors a rest. Because I am on Medicare, the costs of the treatment in my home are covered 100 percent. Home health care is different than many other medical costs which involve a Medicare patient, who must cover up to 20 percent of the average medical bill.
Ultimately, it boils down to what a limb is worth to a person. Often the costs of an amputation exceed the costs of treatment of a wound, even over a protracted period of time. The loss of one's limbs also has a traumatic psychological and functional effect. Having already been through this process twice, I can say that it certainly was no fun losing my feet. Procurin is now another alternative in the arsenal which modern medicine has to treat the ravages of diabetes and other medical conditions which threaten the loss of limbs. For more information about Procurin and wound care treatment, I encourage everyone to contact his/her local wound care center. I would be glad to answer any questins readers may have about my experiences with the treatment, wound care, or amputations. For information contact: Allan Nichols, 1885 Cherry Curt, Apt. C, Cheyenne, Wyoming 82001; or call (307) 638-8037.
by Debra Frank M.S., M.S.
As a diabetic exercise physiologist, I believe in exercising within safe enjoyable limitations. It is documented that exercise enhances both the musculoskeletal system and the biophysical functions of the body. Additionally, the improved body image, self-image and self-esteem seen with positive exercise programming cannot be measured. Having a disease which requires constant checks and balances as well as often unexpected physical and emotional responses makes it hard to try something new or to change a routine. The integration of a slow progressive program of initially supervised exercise can open new doors.
They Ran The Marathon Against All Odds!
Sunday, November 6, 1994 marked the 25th anniversary race of the New York City (NYC) Marathon, one of the most historic sporting events in the world of running. The first NYC Marathon, held on September 17, 1969 with 152 entrants, was won by Gary Muhrcke, an NYC fireman. Twenty-five years later, Gary took another first. He was the first fireman to cross the finish line out of over 160 firefighters who ran amongst a field of over 25,000 runners. The welcoming and incorporation of the Achilles Track Club to the New York Road Runners Club also occurred on this 25th anniversary.
The Achilles Track Club was started by Dick Trump, Ph.D., an amputee athlete who participated in the marathon for the first time 18 years ago. Through his efforts and the support of thousands of other differently-abled athletes around the world, there now exist 111 chapters in 31 countries, stemming from Europe to Mongolia and recently established in areas such as South Africa, Vietnam and Bosnia with 40 chapters in the U.S. The Achilles Track Club invites athletes of all abilities to share in the agony and the ecstasy of adaptive running. This year, 182 Achilles athletes from all walks of life, ages and abilities, were equally represented in the 1994 NYC Marathon. There were over 300 Achilles volunteers and thousands of fans and supporters along the route.
A contingency of athletes from New Zealand and Australia, sponsored by Kentucky Fried Chicken, came half way around the world to participate in this historic event. Craig Jessop, a sharp 27-year-old, blond-haired, blue-eyed New Zealander or Kiwi, who has been challenged by diabetes since age five, joined the determined troupe of athletes. Eager and prepared with his walking cane, he came with his renal nurse to New York City; a city with over seven million residents not including visitors and marathon participants; a city with twice as many people living on an island than the entire continent of New Zealand proper!
Craig was paired with a specially trained, American Achilles volunteer. Miles, a running coach from New Zealand, who had trained with Craig and had successfully escorted him in a 30 kilometer race in the past, joined forces with Debra Frank, an exercise physiologist who has had IDDM for 22 years. Prior to race day, Craig and Debra joined the 21 other diabetic runners from around the world for a pre-race dinner and powwow at the home of John Maddon Esquire, president of the International Diabetic Athlete Association, New York Chapter. The group was positive and physically fit, but the mental power in this room was staggering.
For the race, glucose replacement and test kits were set up every five miles along the route for the 23 runners. For Craig and Debra, this was not convenient since they started three hours earlier than the others and had to cover their own early 'bouncing blood sugars'. This was to be the first time Craig had run or race-walked more than 30 kilometers. The additional 12 kilometers had significant impact on his overall medical and nutritional well-being. Nevertheless, on the morning of the marathon, Craig, Miles and Debra boarded the bus at 5 a.m. with other Achilles athletes and were taken to the start location. The gun for the Achilles athletes went off at 7:30 a.m., three hours before the main race began. Miles was wearing a knapsack with everything from Craig's glucometer, Maro Bars (Kiwi type candy), rain gear, water, Gatorade, trail mix and Debra's rice cakes. Debra had syringes, insulin, a pocket camera and a portable phone in her waist bag. As a safety precaution, Debra had made arrangements with the NYC fire department to have her blood test kits and medical materials at two firehouses on the race course, the 11- and 20-mile points.
At the start of the marathon, Craig had a blood sugar of 194 and Debra had 216. This may sound high, but remember they were nervous and had little sleep. For the type of endurance, non-impact activity they were to perform, the elevated glucose levels would be quickly lowered. As the seconds turned into minutes which rolled into hours, the three athletes shared many stories and managed to keep their spirits up until the bitter end. Debra's blood sugar level was 176 and Craig's was 56 at the end of the race. This low level was quickly raised with leftover goodies. At the finish, Craig expressed his feelings simply by saying, "Finishing this marathon was the ultimate experience of my life. It was like having a seven hour and eleven minute orgasm. All three of us climaxed at the same time and there was no fear of AIDS!!" It is well known that those Kiwis get right to the point and have a tendency to hold little back. Craig is planning to run again in 1995 and this time he is coming to the States with a new addition, a healthy functioning kidney. For information on the Achilles Track Club telephone (212) 354-0300.
Recipes in this issue are from The Diabetic's Innovative Cookbook by Joseph Juliano, M.D. and Dianne Young. This new cookbook is loaded with recipes as well as general diabetes information. Published in 1994 by Henry Holt and Company, the hardcover book costs $25.00.
3/4 lb. medium shrimp (26 to 31 per lb.), peeled
and deveined
11/2 cups shelled fresh or thawed frozen peas
2 tsp. cornstarch
1 egg white
1 tbsp. dry sherry
1/2 tsp. salt Nonstick cooking spray for stir-frying
2 tbsp. finely minced garlic
1 bunch of green onions or scallions, cut into 2-inch lengths
3 tbsp. julienned fresh ginger
1/2 cup drained, sliced low-sodium canned water chestnuts
1 small red bell pepper, stemmed, seeded and julienned
3 cups cooked rice for serving
Rinse the shrimp under cold running water and pat them dry. Split each shrimp in half lengthwise, and then cut each of the halves in two, crosswise. If using fresh peas, blanch them by dropping them in 3 cups of boiling water and boil them for about 5 minutes, at which point they should be tender-crisp. Drain and run cold water over them to stop the cooking. This also helps them hold their color. If using thawed frozen peas, make sure they are fully thawed.
In a large bowl, toss the shrimp with the cornstarch until each shrimp is coated with the cornstarch. In a small bowl, whisk together the egg white, sherry and salt and then stir this mixture into the shrimp and thoroughly combine. Cover and set the bowl in the refrigerator for 45 minutes to 1 hour. Assemble all the ingredients so they are close at hand, as the cooking process takes only a matter of minutes. Remove the shrimp from the refrigerator. Heat a wok, stir-fry pan, or large (10- or 12-inch) skillet over high heat. Lightly coat with the nonstick cooking spray and add the garlic, green onions and ginger. Immediately drop the shrimp into the pan and stir-fry them for about 30 seconds. They should turn bright pink. Drop in the peas, water chestnuts and bell pepper and stir-fry them for about 1 minute to heat them through.
Remove the stir-fry from the pan and transfer to a platter. Serve at once with the hot rice.
Yield: 6; Per serving (2/3 cup plus 1/2 cup rice): 158 calories, 15 g protein, 2 g fat, 23 g carbohydrates, 182 mg sodium; Diabetic Exchanges: 1 starch, 2 lean meats.
1 medium eggplant, halved lengthwise
3 large ripe plum tomatoes, halved
1 medium yellow onion, quartered
5 large garlic cloves, unpeeled
8 large mushrooms, halved
1 medium red bell pepper, stemmed, halved and seeded
1/2 tsp. dried thyme, crumbled
1 tsp. dried basil, crumbled
1 tsp. dried oregano, crumbled Coarsely ground black pepper to taste
2 tbsp. olive oil
1 tbsp. fresh lime or lemon juice Minced fresh parsley for garnish, optional
Jicama sticks or fresh vegetables for dipping
Preheat oven to 400 degrees F. Place eggplant, cut side down, in a large roasting pan. Place the tomatoes, onion, garlic, mushrooms, and bell pepper on top of and around the eggplant. Sprinkle the herbs and black pepper and drizzle the oil evenly over the vegetables. Bake until tender (about 45 minutes). The eggplant is tender when it can easily be pierced with a knife.
Cool and peel the eggplant and garlic. Place them in the bowl of a food processor with a steel blade and add the rest of the vegetables and any liquid. Add the lime juice and puree until the mixture is very smooth. Turn it out into a bowl and garnish with fresh minced parsley, if desired, or chill for future use. (It will keep in the refrigerator for 4 to 5 days and may be prepared in advance.) Serve at room temperature or chilled.
Yield: approx. 4 cups; Per serving (1/4 cup): 37.83 calories, 0.91 g protein, 2.55 g fat, 3.97 g carbohydrates, 76.5 mg sodium; Diabetic Exchanges: 1/2 vegetable, 1/2 fat.
3 tsp. Dijon-style mustard
3 tsp. balsamic or aged red wine vinegar
2 heaping tsp. minced fresh ginger
1/4 tsp. salt substitute
Coarsely ground black pepper to taste
1/4 tsp. cayenne pepper
1/2 tsp. granulated garlic or garlic powder
2 tsp. extra-virgin olive oil
1 lb. fresh green beans, stem ends trimmed (Harvester beans may be substituted
when green beans aren't in season.)
In a 3-quart pot, bring 1/2 gallon of water to a boil over high heat. Meanwhile, put the mustard in a small bowl and then whisk in the vinegar, ginger, salt substitute, black pepper, cayenne pepper, and the granulated garlic. Combine the oils and add them to the mustard mixture as you continue to whisk it rapidly. Drop the beans into the boiling water and boil rapidly for 4 to 5 minutes, until the beans are tender-crisp. Pull the beans immediately from the water and thoroughly drain. Put the beans into a serving dish and toss with the dressing. Serve cold, at room temperature, or hot.
Yield: 4; Per serving (1/2 cup): 70 calories, 2 g protein, 4 g fat, 8 g carbohydrates, 93 mg sodium; Diabetic Exchanges: 1 vegetable, 1 fat.
Nonstick cooking spray for the loaf pan
2 cups all-purpose flour plus
1 tbsp. for dusting the pan
11/2 cups very coarsely chopped fresh or frozen cranberries
1/4 cup blanched sliced almonds
1 tbsp. grated orange zest
2 tsp. grated lime zest
1/4 cup granulated sugar substitute
11/2 tsp. baking powder
1/2 tsp. salt substitute
1/2 tsp. baking soda
2 tbsp. solid vegetable shortening
3/4 cup fresh orange juice or juice made from frozen unsweetened concentrate
Equivalent of 1 egg in egg substitute, thoroughly beaten
Preheat oven to 350 degrees.Thoroughly spray a 9-by-5-inch pan with the nonstick cooking spray. Dust the pan with 1 tbsp. of the flour. In a large bowl, combine the cranberries, almonds and orange and lime zest and set aside. (Note: If you are using frozen berries, they don't need to be thawed; just rinse them, drain well, and pop them into the batter.) In another large bowl, mix together the 2 cups of flour, the sugar substitute, baking powder, salt substitute, and baking soda. Cut in the shortening using 2 forks. Stir in the orange juice and the egg substitute, mixing to moisten the dry mixture.
Fold in the cranberry mixture, being sure to thoroughly combine. Spoon the batter into the prepared pan and bake for about 60 minutes. The bread is done when it is firm in the middle and a toothpick or cake tester inserted in the middle comes out clean.
Cool on a rack for about 20 minutes. Remove from the pan and cool completely. Wrap, refrigerate until chilled (about 2 hours) and serve.
Yield: 1 (9-by-5-inch) loaf; Per serving (1 1-inch slice): 88 calories, 2 g protein, 5 g fat, 14 g carbohydrates, 76 mg sodium; Diabetic Exchanges: 1/2 starch, 1/2 fruit, 1 fat.
by Kenneth Jernigan
This article appeared in the Braille Monitor, December 1994, published by the National Federation of the Blind. Dr. Jernigan is President Emeritus of the Federation.
The time has come to plan for the 1995 convention of the National Federation of the Blind. As Federationists know, our recent National Conventions in New Orleans, Charlotte, Dallas, and Detroit have been record-breaking in every sense of the word Ä excellent programs, good food and facilities, and wonderful hospitality. But Chicago in '95 promises to be the best we have ever had. All you have to do is to remember our Chicago convention in 1988, and you will know what a wonderful experience is in store.
We are going to the Hilton and Towers hotel at 720 South Michigan Avenue in Chicago. You have to be there to believe it. This exquisite hotel, built in the 1920's, originally had over 3,000 rooms. In the 1980's it was remodeled to have only 1,543 rooms, but the elevators (all fourteen of them) and the rest of the infrastructure for a 3,000-room hotel were left intact. Mrs. Jernigan and I have now been to the Hilton and Towers for several planning meetings, and each time I am more impressed than the last.
As usual, our hotel rates are good. For the 1995 convention they are: singles, $47; doubles and twins, $49; triples, $54; and quads, $57. In addition to the room rates, there will be a tax, which at present is almost 15 percent. There will be no charge for children in a room with parents as long as no extra bed is required.
In recent years we have sometimes taken hotel reservations through the National Office, but for the 1995 convention you should write directly to Hilton and Towers Hotel, 720 S. Michigan Avenue, Chicago, Illinois 60605, Attention: Reservations; or call (312) 922-4400. Hilton has a national toll-free number, but do not (we emphasize NOT) use it. Reservations made through this national number will not be valid. They must be made directly with the Hilton and Towers in Chicago.
Here are the convention dates and schedule: Saturday, July 1 Ä seminars for parents of blind children, blind job seekers, and vendors and merchants; several other workshops and meetings. Sunday, July 2 Ä convention registration, first meeting of the Resolutions Committee, other committees, and some of the divisions. Monday, July 3 Ä meeting of the Board of Directors (open to all), division meetings, committee meetings, continuing registration. Tuesday, July 4 Ä opening general session, evening gala. Wednesday, July 5 Ä general sessions, tours. Thursday, July 6 Ä general sessions, banquet. Friday, July 7 Ä general sessions, adjournment.
Remember that we need door prizes from state affiliates, local chapters, and individuals. Prizes should be relatively small in size and large in value. Cash is always popular. In any case, we ask that no prize have a value of less than $25. Drawings will be made steadily throughout the convention sessions. As usual the grand prize at the banquet will be spectacular Ä worthy of the occasion and the host affiliate. The 1994 grand prize in Detroit was a thousand dollars in cash. The 1995 grand prize will be at least as good. Don't miss the fun! You may bring door prizes with you or send them ahead of time to: Pam and Don Gillmore, 5132 West Fletcher Street, Chicago, Illinois 60641-5049.
The displays of new technology; the meetings of special interest groups, committees, and divisions; the exciting tours; the hospitality and renewed friendships; the solid program items; and the exhilaration of being where the action is and where the decisions are being made Ä all of these join together to call the blind of the nation to the Hilton and Towers Hotel in Chicago in July of 1995. Come and be part of it Ä and for further information read the following article from the Illinois affiliate for color and details.
( with one-column agenda box )
Attention blood relatives of persons who have type I diabetes. If you are a first degree relative (son, daughter, parent, brother or sister) of a type I diabetic and are under age 45, or a second degree relative (cousin, niece, nephew, aunt, uncle or grandchild) under age 20, you are needed to be screened for an important major study called the Diabetes Prevention Trial (DPT-1). It began in early 1994 and will continue over the next five to seven years at medical centers nationwide. To be eligible for participation, relatives of people who have Insulin-Dependent Diabetes Mellitus (IDDM) must: not currently have diabetes, have no prior therapy for prevention of IDDM, have no previous history of being treated with insulin or oral diabetes medications, have no known serious diseases, are not planning to become pregnant during the trial period, test positive for islet-cell autoantibodies, and be willing to follow the protocol for one of two medications trials.
Because only three to six percent of all relatives of persons with IDDM are at risk for developing diabetes, an estimated 60,000 first- and second-degree relatives are needed to be screened for islet-cell autoantibodies (ICAs).
Being tested for ICAs is the first step in participation in DPT-1. Arrangements for a free screening can be made by contacting one of several DPT-1 clinical centers in Denver, Boston, Seattle, Minneapolis, Tampa, Gainesville, Miami, Minneapolis, Los Angeles and Stanford, California. Or ask your local physician to assist you and provide him/her with information about DPT-1 and a blood sample kit which comes with instructions. The kit is free and may be obtained by contacting any of the clinical centers mentioned above or the Operations Coordinating Center: Diabetes Prevention Trial (DPT-1), P.O. Box 016960, (D-110), Miami, FL 33101; telephone: 800-HALT-DM1 (800-425-8361). Persons who test positive for ICAs will be eligible for further testing. The Insulin Autoantibodies (IAAs) test measures antibodies produced by the body against its own insulin; the third test, the First-Phase Insulin Release (FPIR), measures the amount of beta cell damage that has already occurred. Information from all three tests, ICAs, IAAs, and FPIR, determines which first- and second-degree relatives are at risk for developing type I diabetes in the next five years.
IDDM is caused by a defect in an individual's immune system which triggers the body to destroy its own insulin producing cells Ä the islet or beta cells. The initial trigger which leads to beta cell loss occurs years before symptoms of diabetes appear. These specialized blood tests, ICAs, IAAs and FPIR, can reliably predict the development of IDDM. The screening tests alone should be a blessing to those who will eventually develop IDDM. They will benefit greatly by having the opportunity for early diagnosis of diabetes long before clinical symptoms appear and can be put on standard diabetes therapy much sooner than would ordinarily happen. Study participants Ä those who have been proven to be at risk but have not yet developed diabetes Ä will test one of two different forms of insulin therapy which scientists believe should delay or prevent the onset of IDDM. There is no charge to participants for tests, procedures or medical treatments. This study requires significant personal commitment in time and energy. However, the long-term reward will be a healthier, longer life for participants.
Inclusion of materials in this publication is for information only and does not imply endorsement by The Diabetics Division of the NFB.
Food is an important issue for diabetics. "Living With The Diabetic Diet" by Josephine D. Hunt, R.D. and licensed nutritionist, is a 45-minute video tape containing a complete explanation of the diabetic diet. A sample menu plan, advice on eating in restaurants, and steps to control blood sugar are also included.
Each copy costs $39.95 plus $5.00 shipping and handling. Mastercard and Visa accepted. To order a copy contact: The Hunt-Moore Group, 216 Scenic Drive, Tullahoma, TN 37388; telephone: 1-800-891-7833.
Aicom Corporation of San Jose, CA, offers three models of the Accent text-to-speech synthesizer, a device that converts text on your computer screen to speech. It has a vocabulary of over 20,000 words. The models include a full-length PC plug-in card for IBM-PC compatibles ($745), a stand-alone unit with RS-232C link to any computer ($995), or the Messenger-IC PCMCIA Type II ($995), as well as others. The Accent is supported by all major screen-reader programs. For further information contact: Aicom Corporation, 1590 Oakland Road, Suite B112, San Jose, CA 95131; telephone: (408) 453-8251; fax: (408) 453-8255.
This article appeared in the Observer, Autumn, 1994, published by the National Federation of the Blind of Wisconsin.
On August 16, 1994, National Federation of the Blind President Marc Maurer held a news conference at the National Center in Baltimore to announce the initiation of the talking newspaper, USA Today. The paper is now available by telephone. With cosponsors USA Today, Corporation for Public Broadcasting, WBGH, and the National Center for Accessible Media, the National Federation of the Blind has an exciting new program which could be the start of something very big and exciting for blind people all over the United States.
Using the software produced by Voice Data Systems, which is given to those who use the newspaper, the paper is not read by human voice, but all by computer programming and state-of-the-art synthesized speech. The information comes to the National Center from USA Today each morning by telephone wire at 6:15 AM.
By 6:30 AM the data has been handled by the software, which puts it in a form you can access by touch tone phone. Then any blind person subscribing to the service can call and get the information read to them on the telephone.
The computer program allows the listener choices by having a menu. There are four sections: news, money, sports, and life. And while you're in a particular section, you can jump ahead a bit or back up and re-read a sentence or paragraph. You can also change the sound of the voice for your own preferences.
There is no charge for access to the paper. However, you must register and obtain a special access code from the National Center by calling (410) 659-9314. Then you get an identity number and a security number. The paper is currently available as a local call in the Washington, D.C. and Baltimore exchanges. Efforts are under way to seek funding to make the telephone service accessible on a toll-free line.
Developed for diabetics with unsteady hands and those who are blind or losing vision, the new Smart Dot Blood Collector-Dropper places the droplet for a glucose reading from Lifescan's One Touch II or One Touch Basic meter. With a 30-day money-back guarantee, it costs $10.95 plus $3.50 shipping and handling. Visa, Mastercharge, Discover and AMEX are accepted. To order, contact Smart Dott, 2655 West Central Ave., Toledo, Ohio 43606; telephone: 1-800-984-1137.
The NFB Diabetics Division has an updated Resource List of Aids and Appliances. This list is a compilation of companies and individuals offering products and/or information for diabetics, especially those who are blind or are losing vision, to help them selfmanage their diabetes. This comprehensive list is arranged under five subject categories: General and Miscellaneous, Automatic Insulin Injection Systems, Blood Glucose Monitoring Systems, Insulin Pumps, and Large Distributors of Diabetes Equipment and/or Supplies. The blind can and do accurately draw up insulin, monitor blood glucose, etc. They can continue being independent, and by using alternative techniques and products they can control their diabetes as efficiently as do their sighted peers. Limitations are usually self-imposed Ä often all that is needed to overcome negative thinking is simply to know where to go for information. The new Resource List costs $2.00 per copy and is available in Braille, large print, and audiocassette. Make checks payable to National Federation of the Blind (Visa, Mastercard or Discover also accepted). Order from: National Federation of the Blind, Materials Center, 1800 Johnson Street, Baltimore, MD 21230; telephone: (410) 659-9314.
Can-Am Corporation carries a full line of diabetes supplies such as test strips, glucose supplements, skin cream, etc. The company recently announced that they now manage the retail distribution and consumer marketing for Sherwood Medical Company's Monoject line of insulin syringes and lancets. Monoject supplies are sold nationally by diabetes suppliers. For information, contact: Can-Am Care Corporation, Cimetra Industrial Park, Box 98, Chazy, NY 12921-0098; telephone: 1-800-461-7448.
Diabetics who regularly test blood glucose levels know that test strips are expensive. Costs can vary widely, so wise consumers will shop around. Here is an example: On March 8 in Columbia, Missouri, K-Mart was selling 50 Life Scan One-Touch test strips for $34.99. They also offered 50 Relief Plus Strips for $24.99, which allegedly work with One-Touch meters. Consumers, shop around and be rewarded.
DiabetiDerm is a new moisturizing lotion and cream. It is formulated with urea, alpha hydroxy, and silk proteins to address severely dry skin. The product is also non-irritating, free of fragrances and artificial colors, and is non-comedogenic. DiabetiDerm is offered in an 8oz. lotion as well as a 4oz. cream.
For information contact: Gary M. April, V.P. of Sales and Marketing, Health Care Products, 369 Bayview Ave., Amityville, NY 11701; telephone: 1-800-899-3116 or fax: (516) 789-8429.
The National Federation of the Blind (NFB), the largest and oldest organization of blind people in existence, has a Materials Center offering a wide selection of aids and appliances for blind people of all ages. A non-profit organization, the NFB is not seeking retail price income from the items it sells. Since there is a high incidence of blindness from diabetes, the NFB Materials Center is now offering the following products at substantially reduced prices.
Low Dose Count-A-Dose Insulin Measuring Device: Calibrated for use with B-D 1/2 cc syringes only. Turning a thumb-wheel produces clicks, heard and felt, that measure one-unit increments. Holds one or two vials of insulin for mixing; needle penetrates vial stopper automatically. Print and cassette instructions. Cost: $40.
Count-A-Dose Insulin Measuring Device: Very similar to above, but uses B-D U-100 1 cc syringes only, and measures in two-unit increments. May be a good choice for diabetics who draw larger doses of insulin. Out of production; limited supply available. No cassette instructions. Cost: $40.
LifeScan One Touch II Blood Glucose Monitor: Provides accurate results in 45 seconds. No cassette instructions included. Cost: $120. The Materials Center offers test strips for this glucometer; a bottle of 50 is priced at $33.
Voice Synthesizer for the LifeScan One Touch II: This module, the Voice-Touch, attaches firmly to the glucometer, providing audio output. A switch allows choice of male or female enunciation. The voice-synthesizer is shipped with large print and easy-to-understand cassette instructions. Cost: $219. Optional AC adaptor costs $11.
Talking Blood Pressure Meter: Gives systolic/diastolic and pulse readings, both spoken and on oversize LCD display. Portable, runs on four AA batteries (included). Cost: $169. The unit is shipped with a standard size cuff. Smaller cuffs cost $15, and larger cuffs are available for $20 each.
Talking Clinical Thermometer: Provides audible readout of body temperature. Large print and cassette instructions. Cost: $49.
Talking Scale: Electronic digital scale provides audible readout of weight in either kilograms or pounds. Uses one 9-volt battery (included). Cost: $80.
Prices do not include shipping and handling. To order any of the above, or to receive a free products catalog, in Braille or print, contact: National Federation of the Blind, Materials Center, 1800 Johnson Street, Baltimore, MD 21230; telephone: (410) 659-9314. Visa, Mastercard, Discover, or personal check accepted.
Artificial eyes have been around for thousands of years, while the first ocular implants were developed a century ago. Due to improving technology, six years ago a new implant was approved by the FDA called Bio-eye hydroxyapatite ocular implant. This implant, made with material from ocean coral, reduces implant drifting within the ocular orbit and rejection by body tissues. A method of transforming the mineral in certain coral species to match that of human bone, known as hydroxyapatite, was discovered because of the similarity between bone and coral. The naturally derived hydroxyapatite matches both the porous and chemical structure of bone. Body tissues will accept the Bio-eye implants more readily than the earlier, first-generation ocular implants.
In the surgical implantation procedure, administered under local or general anesthesia, the Bio-eye implant is placed into the ocular orbit and the muscles are attached to the implant. After six to eight weeks, the artificial eye is fitted over the implant. It will move as the implant moves or track along with the natural eye.
An optional procedure to maximize eye movement can be done six months after implantation. In this procedure, a hole is drilled into the implant and a peg is inserted into the hole which will also attach to the artificial eye, thus forming a ball-and-socket joint.
It is reported that the entire procedure costs up to $6,000, and most insurance companies cover this expense. For more information on the Bio-eye hydroxyapatite ocular implant consult your opthalmologist or ocularist or contact: Integrated Orbital Implants, Inc., 12526 High Bluff Dr., Ste. 300, San Diego, CA 92130-2067; telephone: 1-800-424-6537.
The following information is from the Geddings D. Osbon, Sr. Foundation, P.O. Box 1593, Augusta, GA 30903; telephone: 1-800-433-4215.
Diabetes is a leading medical cause of impotence. In fact, it is estimated that over half of all diabetic men over the age of 50 will become impotent.
Physical Causes of Impotance:
Vascular Disease: 40% Diabetes: 30% Nerve Disorders: 10% Pelvic Surgery, Injury: 9% Rx Drugs, Substance Abuse: 8% Hormonal Deficiency: 3%
Steuart Laboratories of Harmony, Minnesota has developed a foot cream which combines the natural antiseptic Melaleuca Oil, and other natural oils, in a vanishing cream base. The cream can be used on slow healing sores and for itching, dry, cracked skin on the feet and legs. Reports state that the cream penetrates rapidly and leaves no greasy film. A two-ounce jar costs $9.25 plus $2.50 for shipping. To order contact: Steuart Labs, P.O. Box 297, Harmony, MN 55939; telephone: (507)-886-2661.
The Exchange List for Meal Planning is now available in Braille (83 Braille-written pages bound in a durable, plastic cover) and on audio cassette.
This revision, the result of a joint effort of the American Diabetes Association and the American Dietetic Association, reflects today's food values and eating patterns. It continues to restrict fat but emphasizes high carbohydrate and fiber foods. Nutritive values have been increased for such foods as fruits and milk products, and for carbohydrate/starch exchanges. New additions include a list of free foods, exchange values of food combinations, and a list of foods for occasional use. There is also a glossary of nutritional terms and an index of foods.
Make tax deductible checks payable to: National Federation of the Blind. Cost: Braille $10.00, and cassette $2.00. Order from: National Federation of the Blind, Materials Center, 1800 Johnson Street, Baltimore, MD 21230; telephone: (410) 659-9314.
The Count-a-Dose is a syringe filling device designed especially for diabetics who are blind or are losing vision so that they may independently and accurately draw up their own insulin. It fills in one-unit increments and uses the B-D 50-unit (1/2 cc) syringe. As each unit of insulin is drawn, the device makes a distinct click which can be heard and felt. The device holds one or two bottles of U-100 insulin for easy mixing. Print directions and an instructional cassette tape are included. The Count-A-Dose costs $49.95 and may be ordered from Jordan Medical Enterprises at 800-541-1193.
The following is adapted from AADE News, February 1995, published by the American Association of Diabetes Educators.
The AADE announced a handbook for people with diabetes. It said in part: "These days, trying to decipher the food labels one encounters at the grocery store can be an intimidating task Ä especially for people with diabetes who need to pay special attention to labels and their nutrition facts." Making healthy food choices are important. Reading Food Labels: A Handbook for People with Diabetes is available for purchase in quantities of 25 at $4.15 (AADE members); $5.00 (nonmembers).
Please order from: AADE, 444 N. Michigan Ave., Ste. 1240, Chicago, IL 60611-3901; telephone: (312) 644-2233.
We invite blurbs and tidbit articles for inclusion in this column. Materials received may be edited and used as space permits. Products and services included in this column are for information only and do not imply endorsement by The Diabetics Division of the NFB.
The following will help your diabetes educator give you the best advice for staying healthy.
Be sure to talk to your educator about:
Brought to you by Becton Dickinson and Company and Boehringer Mannheim Corporation, committed to advanced care and education in diabetes.
During this year's national convention in Chicago, Illinois (Saturday, July 1 through Friday, July 7) dialysis will be available. Individuals requiring dialysis must have a transient patient packet and physician's statement filled out prior to treatment. Conventioneers should have their unit contact the desired location in the Chicago area for instructions on what must be done. Unit social workers should also contact the Shearer Program, American Kidney Fund, 6110 Executive Blvd., Suite 1010, Rockville, MD 20852; telephone: 1-800-638-8299. Shearer will pay the Medicare 20 percent co-payment (approx. $30) for transient dialysis, as well as any physician's fees for treatment. The program, however, does not cover the drug Erythropoietin, chart readings, or lab work.
If Shearer is not used, individuals must pay out of pocket, prior to each treatment, the approximate $30 not covered by Medicare. Note: If patients wish reimbursement, receipts must be sent to the American Kidney Fund Shearer Program no later than two weeks after the last day dialyzed.
DIALYSIS CENTERS SHOULD SET UP TRANSIENT DIALYSIS LOCATIONS USING THE SHEARER PROGRAM FAR IN ADVANCE. THIS HELPS ASSURE A LOCATION BEING RESERVED FOR ANYONE WANTING TO DIALYZE.
If conventioneers do not have Medicare, but have Medicaid, Shearer will pay $200 towards the cost of dialysis each year.
1. NEO Medica Dialysis Center Inc., One East Delaware, Chicago, IL 60611; telephone: (312) 266-9000. Location is fairly close to the convention center. To schedule, call patient representative Marie Mason (312) 654-2785.
2. Northwestern Memorial Hospital, Northwestern Dialysis Unit, 250 East Superior, Chicago, IL 60611; telephone: (312) 908-3327. Location is fairly close to the convention center.
3. Hyde Park Kidney Center, 1439 East 53rd St., Chicago, IL, 60615; telephone: (312) 947-0770. Location is approximately 50 blocks from the convention center. Taxi fare is about $15, so pooling will minimize cost. This unit claims they can handle ten to fifteen patients with adequate notice. Contact Ruth Ann Riley.
Please remember to schedule dialysis treatments posthaste to insure space. If assistance is needed contact: Diabetics Division President Ed Bryant at (314) 875-8911. See you in Chicago!
At this year's national convention in Chicago, Illinois, elections will be held to fill divisional board positions. These are one-year terms that will run from July 1, 1995 to June 30, 1996. Positions to be filled are: President, First Vice-President, Second Vice-President, Secretary, and Treasurer. If you are interested in a board position, or know someone who you think would do a good job, then contact our Diabetics Division President Ed Bryant. Yes, hard work and dedication are prerequisites for each board position. Anything worthwhile is usually challenging and requires hard work. Leadership should be a positive force, and one should lead by good example.
We have been asked to announce: The Matilda Ziegler Magazine for the Blind has moved to a new office in Manhattan. Their mailing address is: 80 Eighth Avenue, Room 1304, New York, NY 10011; telephone: (212) 242-0263 or fax: (212) 633-1601.
The monthly magazine, founded in 1907, covers a wide range of subjects and gives news of interest to blind and visually impaired persons. It is published in Grade 2 Braille and on four-track, half-speed cassette.
The National Federation of the Blind of Florida proudly announces a new Diabetics Division coordinator. The position is held by Teri Gayton of Citrus, FL. Teri is capable, hard working, and has a vibrant personality. She adds a lot to the NFB of Florida's ability in serving those with diabetes and blindness.
Congratulations, Teri. You have earned the appointment.
Diagnostics Solutions, Inc. has announced a recall of certain blood glucose test strips for use with Glucometer 3 and One Touch meters. The recall applies to test strips (specific lot numbers only) packaged under brand names: Quick Check, Brooks, Full-Value, Perry, Relief-Plus, and Valu-Rite.
"We identified these test strips as not meeting our strict quality guidelines for long-term product stability," said Gary Krantz, president of Diagnostic Solutions.
Users may contact the Diagnostic Solutions Recall Coordinator at 1-800-446-4374 for further information regarding their test strips and to obtain replacements on a "two-for-one" basis.
We have been asked to announce: The American Printing House for the Blind (APH) offers a portable electronic magnifier that enlarges print images onto a television screen.
The device, called the Big Picture, connects to the antenna or cable TV input on the back of a television. With a miniature camera attached to a controller, the user can scan any typed or handwritten material on paper, medicine bottles or canned goods. Depending on the size of the screen, the print can be manipulated for easier reading. The Big Picture comes in a compact carrying bag with connecting cables and a power adaptor.
To order, or for information, contact the APH at 1-800-223-1839.
The Diabetics Division of the National Federation of the Blind reaches out, providing support and information to thousands of people. Because it costs to operate this valuable network and to produce the Voice of the Diabetic, we must generate funds to help cover these expenses. Our Diabetics Division has elected to hold a raffle. This project will be coordinated by our treasurer, John Yark.
THE GRAND PRIZE WILL BE $500! The name of the winner will be drawn on July 6, 1995 at the banquet held during the annual convention of the National Federation of the Blind.
Raffle tickets cost $1.00 each or a book of six may be purchased for $5.00. Tickets may be purchased from state representatives of our Diabetics Division or by contacting the Voice Editorial Office, 811 Cherry Street, Suite 309, Columbia, MO 65201; telephone: (314) 875-8911. Anyone interested in selling tickets should also contact the Voice Editorial Office. Tickets are available now! Names of persons who sell 50 tickets or more will be announced in the Voice.
Please make checks payable to the National Federation of the Blind. Money and sold raffle ticket stubs must be mailed to the Voice office no later than June 16, 1995 or they can be personally delivered to Raffle Chairman, John Yark, at this year's NFB convention in Chicago, Illinois. This raffle is open to everyone. The holder of the lucky raffle ticket need not be present to win. Each ticket sold is a donation which helps keep our Diabetics Division moving forward.
The 1995 Annual Convention of the National Federation of the Blind will take place July 1 through 7 at the Hilton and Towers Hotel, 720 S. Michigan Avenue, Chicago, Illinois 60605, (312) 922-4400. This exquisite hotel has over 1500 rooms with 14 elevators. Room rates for the 1995 convention are: $47, singles; $49, doubles and twins; $54, triples; and $57, quads; plus tax.
During the annual convention of the NFB, our Diabetics Division will sponsor a seminar featuring a keynote speaker.
The NFB Diabetics Division will hold a seminar at this year's National Federation of the Blind annual convention. It is our yearly Diabetics Division conference/business meeting. This year's keynote speaker will be a registered dietician with expertise in diabetes food management. Pertinent dietary information, relevant to diabetics, will be discussed. This meeting will take place on Monday, July 3, beginning at 6:30 p.m. The conference location will be in the agenda, available at the registration table.
Plan, prepare, and be rewarded. This year's convention will be great!
At this year's annual convention of the National Federation of the Blind there will be many insulin-dependent diabetics in attendance. Each of us should have the foresight to bring extra insulin and syringes so as to avoid needing to go in search of a pharmacy.
At every convention, a few diabetics undergo avoidable hypoglycemic attacks. Hotels are jammed, and restaurants are packed, with long waits for a table. We insulin-dependent diabetics should always be prepared for an insulin reaction.
THINK AHEAD! Always carry something sweet, such as candy or glucose tablets, that can be used for reactions. We should be sure to have, in our rooms, snack foods to help control our food needs.
We diabetics can travel anywhere and do almost anything we want. One thing we cannot do is go without food. Our bloodstreams should have a balance of insulin and glucose. If there is not enough glucose (food) then we have an "insulin reaction."
"Plan ahead and be prepared."
We have been asked to announce: A first study by the Johns Hopkins Medical Institutions indicates that even small increases in blood pressure in men can lead to kidney failure over a 15-year period.
According to the author of the study, Michael J. Klag, M.D., M.P.H., the finding is significant because end-stage renal disease is becoming more common, in the United States, than any other blood pressure-related diseases. These findings were independent of age, race, number of cigarettes smoked, previous heart attacks, diabetes, income, and serum cholesterol. (Editor's Note: Diabetic men and women with high blood pressure are far more prone to renal disease.)
This year the Diabetics Division of the National Federation has reserved space in the exhibit hall, where we will display literature and equipment of interest to blind diabetics and others interested in diabetes. There will be hundreds of other display tables with products and information that may be of interest to blind persons.
CAN YOU HELP? It takes many people to work the display tables, and if you can help for two hours, four hours, or more, please contact our Display Table Committee Chairman: Bill Parker, Lafayette Tower, 4601 Mayflower Road, Apt. 2D, Norfolk, VA 23508; telephone: (804) 623-1638.
We have been asked to announce: WQCS Classic 89 FM now offers a Radio Reading Service for the Blind, Visually, and Physically Impaired. The primary purpose of this new program is to read for those who can no longer read on their own.
The Radio Reading Service can only be picked up on an SCA receiver that will broadcast from South Brevard County to a portion of the Palm Beaches. The service, receiver, and delivery of the receiver are free of charge to all eligible persons within the listening area. Programming will be 24 hours a day and will consist of most local and national newsstand publications, magazines, old radio dramas, etc.
For information about receiving service or volunteering contact: WQCS Radio Reading Service, Attn.: Peemoy K. Walters, P.O. Box 89, Fort Pierce, FL 34979; telephone: (407)-462-4537.
We have been asked to announce by a leader of our Diabetics Division: I have a condition my doctor calls "dry gangrene." Although it is not quite as threatening as the kind that involves an infection, it is nevertheless serious and painful. Dry gangrene is caused by blood vessels in the fingertips closing down completely due to such complications as diabetes and some transplant medications.
Anyone who has suffered this particular condition or has information, please contact: Allan D. Nichols, 1885-C Cherry Court, Cheyenne, WY 69201; telephone: (307)-638-8073.
We have been asked to announce: in case of an emergency, the attending physician or paramedic needs to know you have diabetes. To receive a necklace at no charge contact: Free Diabetes Alert Necklace, Children's Diabetes Research Foundation of America, Inc., 1200 Potomac St. NW, Suite 300, Washington, D.C. 20007; telephone: (202) 298-9211.
The Diabetics Club of Northern Nicaragua requests information about diabetes to educate people about the disease and is in urgent need of supplies. For information please contact: Ricardo Calero, Presidente del Club de Diabeticos, Comedor Sequiera, del Centro de Salud Leonel Rugama , 1/2 Cuadra Al Norte, Esteli Nicaragua.
We have been asked to announce: After 17 months of litigation, an out-of-court settlement was reached between LifeScan, Inc. and Can-Am Care Corporation over the selling and advertising of Can-Am Care's Quick Check ONE blood glucose test strips.
Under a new licensing agreement granted by LifeScan, a Johnson & Johnson company, Can-Am Care is guaranteed the right to continue selling and advertising Quick Check ONE test strips. Originally, LifeScan had filed for patent infringement. They also sought a preliminary injunction to block the sale and advertisement of Can-Am Care's less expensive test strips because they were designed for LifeScan's One Touch meters. Clinical studies have shown that Quick Check ONE test strips are as effective as One Touch strips. For information call Can-Am Care Corporation at 1-800-461-7448.
Since the Voice is now offered free, our Diabetics Division will provide extra copies to anyone wanting to help spread the word. We will gladly send from five to five hundred-plus copies each quarter to be used as free literature. Medical facilities can order as needed for patients. Individuals can usually place copies of the Voice in libraries, pharmacies, hospitals, doctors' offices, or other public locations.
Diabetes education is essential. Anyone who distributes the Voice will be helping people with diabetes, and their families, to learn about the disease and its ramifications; to learn that they have options; and that their world is far greater than whatever "limits" may be imposed by the disease. If you would like to help spread the word by distributing the publication, please contact: Voice of the Diabetic, 1412 I-70 Drive SW, Suite C, Columbia, MO 65203; telephone: (573) 875-8911.
If you or a friend would like to remember the Diabetics Division of the National Federation of the Blind in your will, you can do so by employing the following language: "I give, devise, and bequeath unto the Diabetics Division of the National Federation of the Blind, 1800 Johnson Street, Baltimore, Maryland 21230, a District of Columbia nonprofit corporation, the sum of $______________" (or "______________ percent of my net estate" or "the following stocks and bonds: _______________") to be used for its worthy purposes on behalf of blind persons."
Voice of the Diabetic is a national publication of The Diabetics Division of the National Federation of the Blind. It is read by those interested in all aspects of blindness and diabetes. We show diabetics that they have options regardless of the ramifications they may have had. We have a positive philosophy and know that positive attitudes are contagious!
News items, change of address notices and other magazine correspondence should be sent to: Ed Bryant, Editor Voice of the Diabetic 1412 I-70 Drive SW, Suite C, Columbia, MO 65203 Phone: (573) 875-8911
Copyright ©1995 The Diabetics Division of the National Federation of the Blind. ISSN 1041-8490